The Secondary Survey Clay Cothren Burlew, MD FACS Director, Surgical Intensive Care Unit Attending Surgeon, Denver Health Medical Center Associate Professor of Surgery, University of Colorado Outlining the Resuscitation • ABCs Completed – adjuncts to the 1° survey – start 2° survey • History/Mechanisms of Injury • Examination: – injury identification – intervention and treatment – management pitfalls • Take Home Points Outlining the Resuscitation Resuscitation Primary Survey Secondary SurveyDefinitive Treatment Reassessment PITFALL Be wary of the transient responder….. Adjuncts to the ABCs • ECG monitoring – tachycardia – dysrhythmias – ST segment changes • Fetal monitoring – > 26 weeks – high-risk for 24° Adjuncts to the ABCs • Catheters – foley – NG tube PITFALL • Suspect urethral injury – blood at meatus – perineal bruising foley – high-riding prostate – pelvis fracture PITFALL • Appropriate NG tube use: – may precipitate gagging – emesis/aspiration – avoid nasal route in patients with facial fx Adjuncts to the ABCs • Portable X-rays - blunt trauma • AP chest “Big 3” • AP pelvis • lateral c-spine Adjuncts to the ABCs • Portable X-rays - penetrating trauma • “injured space plus 1 above/below” Adjuncts to the ABCs • FAST exam: – 4 views of abdomen – >200cc of fluid LIVER CARDIAC CHAMBERS Right Upper Quadrant Left Upper Quadrant Pericardial Pelvis PITFALL If persistent or recurrent hypotension, remember FAST isn’t 100% accurate! Secondary Survey: History • A = Allergies • M = Medications • P = Past illnesses/Pregnancy • L = Last meal • E = Events around injury Secondary Survey: History • Prenatal history: – PIH, DM, CHD – preterm labor – placental abruption/previa – fetal movement • Fundal height fetal age Secondary Survey: History • Blunt Mechanisms: – seat belt/helmet use – vehicle damage – steering wheel deformation – impact direction – passenger ejection – deaths at the scene Secondary Survey: Mechanism • Front impact: – C-sp fx, rib fx ± PTX, liver/spleen lacs, post hip dislocation • Side impact: –C-sp fx, rib fx ± PTX, diaphragm rupture, pelvis fx • Ejection: –increased risk Secondary Survey: Mechanism • Penetrating trauma: – body region – GSW: distance from weapon to wound, velocity, caliber, presumed path – SW: length of object, impact direction – associated blunt trauma? PITFALL If the weapon is in the patient, allow the surgeon to remove it under controlled conditions! Secondary Survey: Exam Head to Toe “Every Nook and Cranny” Exam: HEENT • Head: – scalp lacerations or contusions – skull fractures Exam: HEENT • Eye: – pupil exam – globe intact? – visual acuity? • Ears: – blood? CSF leak? – intact? Exam: HEENT • Nose/Mouth/Throat: – airway issues paramount – bony step-off – bite feels normal? – bleeding from nose/mouth Penetrating Neck Injuries Hemodynamically Unstable Uncontrolled Hemorrhage PENETRATING Operative NECK INJURY Exploration Penetrating Neck Injuries Hemodynamically Unstable Uncontrolled Hemorrhage CT CTA + Zone I neck/ esophagram bronchoscopy chest Hemodynamically Stable Operative PENETRATING Zone II Symptomatic** Exploration NECK INJURY Zone III Angio + IR embo ** symptoms = expanding hematoma airway compromise dysphagia subcutaneous emphysema hoarseness Penetrating Neck Injuries Hemodynamically Unstable Uncontrolled Hemorrhage CT CTA + Zone I neck/ esophagram bronchoscopy chest Hemodynamically Stable Operative PENETRATING Zone II Symptomatic** Exploration NECK INJURY Zone III Angio + IR embo CT CTA + Zone I neck/ esophagram bronchoscopy chest Transcervical GSW Asymptomatic Zone II All Others Observe ** symptoms = expanding hematoma Zone III airway compromise dysphagia subcutaneous emphysema hoarseness Exam: HEENT • The Brain! – evaluation part of ABCDEs – calculate GCS • GCS < 8 severe head injury/coma – Dx = CT scan, ICP monitor Exam: Spine • Cervical/Thoracic/Lumbar: – always protect the spine – safely off the backboard – if one fx, look for another! – sensory/motor loss = injury – steroids?? – complication = neurogenic shock Exam: Thoracic Injuries • 8 Lethal Injuries: – pneumothorax – hemothorax – pulmonary contusion – blunt cardiac injury – aortic disruption – diaphragm rupture – tracheobronchial injury – traversing mediastinal wounds Exam: Thoracic Injuries • Simple pneumothorax – penetrating and blunt – lung laceration with air leakage – ↓ breath sounds – hyperresonance • Tx = chest tube Exam: Thoracic Injuries • Hemothorax – lung laceration or laceration of intercostal vessel – bleeding self-limited before chest tube – <10% require • Txthoracotomy = chest tube • If > 1500cc out initially thoracotomy after chest tube PITFALL Make sure blood is evacuated – R/O caked hemothorax. Exam: Thoracic Injuries • Pulmonary contusion – most common injury – develops over time – present without rib fx in children admit • Tx = intubation if significant hypoxia 12 hrs Exam: Thoracic Injuries • Blunt cardiac injury – contusion to any chamber – occasional rupture – clinical symptoms: • tachycardia • arrhythmias • abnormal ECHO • Tx = 24˚ of Telemetry Swan if ECHO abnormal, patient unstable Exam: Thoracic Injuries • Aortic disruption – complete transection – typically DOA – incomplete tear – potentially salvageable – injury near ligamentum arteriosum – contained hematoma Exam: Thoracic Injuries • Aortic disruption – few symptoms – X-ray findings: • wide mediastinum • obliterated aortic knob • deviation of trachea • depressed left bronchus • deviation of esophagus • apical capping Exam: Thoracic Injuries • Aortic disruption – empiric treatment in trauma bay • esmolol SBP < 100, HR < 100 – screening helical CT scan – angiography is the gold • Tx standard= operative repair vs. stent graft Exam: Thoracic Injuries • Diaphragm rupture – more common on left – blunt = radial tear – penetrating = linear lac left diaphragm rupture • Diagnosis – gastric bubble in chest – liver in the chest – NGT coiled in chest right diaphragm rupture Exam: Thoracic Injuries • Dx = CT scan can be confirmatory • Tx = operative repair via the abdomen Exam: Thoracic Injuries • Tracheobronchial Injury – within 1 inch of carina – often lethal – hemoptysis, subQ emphysema, tension pneumothorax – persistent air leak – bronchoscopy • Tx = watch vs. glue vs. operate Exam: Thoracic Injuries • Transmediastinal Wounds – external wounds + Xray • Tx = determined by hemodynamics – stable – CT, triple eval – unstable – OR • Mortality > 20-40% KEY POINT Rule out the 8 lethal chest injuries. Exam: Abdominal Injuries • Blunt trauma = crushing injury • Penetrating = laceration • Organ injuries – blunt = spleen liver bowel – SW = liver bowel diaphragm – GSW = bowel colon liver Exam: Abdominal Injuries • Diagnostic tools: – FAST exam blood in the abdomen? – Plain film retained bullet? – DPA/DPL blood? bowel contents? – CT scan specific injury? Blunt Abdominal Trauma Hemodynamically Stable No Yes FAST + Peritonitis? Yes Yes No Equivocal + DPA LAPAROTOMY FAST + Yes No Abdominal CT Yes Indications for CT: No Repeat FAST -Altered mental status in 30 minutes -Confounding injury -Gross hematuria -Pelvic fracture -Abdominal tenderness -Unexplained Hct<35% Penetrating Abdominal Trauma Hemodynamically Unstable Anterior Penetrating Abdomen Abdominal GSW RUQ Trauma Tangential Back/Flank CT + Scan Operatin Hemodynamically g Stable Room Back/Flank SW Serial AASW Exams + with and + LWE Labs Exam: Abdominal Injuries Blunt liver injury: Penetrating liver injury: Exam: Abdominal Injuries Blunt spleen injury: Exam: Abdominal Injuries Blunt pancreatic/duodenal injury: Exam: Abdominal Injuries Blunt bowel injury: Exam: Pelvic Injuries • Exam – stable pelvic ring? • Pelvis film – intact circle? – rami intact? – acetabulum smooth? Exam: Pelvic Injuries • If patient has a pelvic fracture – rectal exam bony fragments? – vaginal exam lacerations? – GU exam bladder/urethral injury? – perineal exam degloving? Pelvic Fracture KCP FAST Exam Positive Operating Room Laparotomy, Pelvic Fixation and Pelvic Packing Assess Tube Thoracostomy Output Yes Hemodynamically Stable? SICU +/- CT scans** Ongoing Transfusion Requirements? No Yes No Angiography ** normalize coagulation status, SICU abdominal CT scan if no laparotomy done. Pelvic Fracture KCP FAST Exam Positive Negative Operating Room 2 units PRBCs/ED trauma bay HD Unstable HD Stable Laparotomy, Pelvic Fixation and Pelvic Packing Assess Tube Thoracostomy Output Operating Room Yes Hemodynamically Stable? SICU +/- CT scans** Pelvic Fixation and Pelvic Packing Re-ultrasound Abdomen Assess Tube Thoracostomy Output Ongoing Transfusion Requirements? No Yes No Angiography ** normalize coagulation status, SICU abdominal CT scan if no laparotomy done. Exam: Extremity Injuries • Exam – deformity? – open fracture? – intact motor/sensory exam? – pulses? • Stop bleeding with pressure • Measure A-A gradient • Traction/splints 2º Survey: Take Home Points • Systematic evaluation • Recognize and treat life threatening injuries • Ongoing resuscitation • Diagnostic tests • Watch for pitfalls Questions? ?.